10 yr experience of TOTALY laparoscopic pouches for UC
Laparoscopic restorative procto-colectomy: a 10-year experience of an
Goede, AR Dixon. Dept., Colorectal
Surgery, Frenchay Hospital, North Bristol NHS Trust, BS16 1LT
Mr Tony Dixon.
Ileal pouch-anal anastomosis,
Laparoscopic restorative procto-colectomy, SILS, Single port surgery
Large, long-term randomized controlled trials of
laparoscopic surgery for colorectal cancer (MRC CLASICC1, COST2 and
Barcelona3 trials) have all concluded that it is safe and
associated with better short-term outcomes and without any compromise to
long-term cancer survival. NICE recommend4 that NHS trusts
gave patients the option of laparoscopic resection as an alternative to open
surgery provided that appropriately trained surgeons performed it. Restorative proctocolectomy (RPC) can also be
performed using laparoscopic techniques5 -13. The surgery however is technically challenging and time consuming,
and this will no doubt add to the ongoing debate regarding precisely how and
where pouch surgery should be conducted. The aim of this study was to report
our up-to-date experience of laparoscopic assisted and “total” laparoscopic RPC
and highlight the difficulties of these two approaches.
Patients and methods
A prospectively collected, password protected electronic
database of all colorectal laparoscopic procedures performed between October
1999 and April 2010 has been used to identify surgical outcomes in 71
consecutive patients who have undergone laparoscopic restorative proctectomy –
ileal pouch anal anastomosis (LRPC).
Our initial 3-port technique utilizing rectal
mobilization within the TME plane, close division of the colonic mesentery with
omental preservation has been previously described9. A 6cm
Pfannenstiel incision was utilized in the first 40 patients to allow closure of
the gut tube 1cm above the dentate line using the TX30G (Ethicon Endosurgery, Bracknell, UK), transection and retrieval of
the rectum followed by construction of a 12cm W pouch. The pouch anal
anastomosis was constructed under direct vision using a double staple technique.
A suitable portion of ileum was chosen for the diverting loop ileostomy and
drawn through the enlarged 12mm right iliac fossa (RIF) port-site. The
subsequent 31 unselected patients underwent total laparoscopic mobilization
with the specimen delivered (divided rectum end first) through the suitably
dilated port at the site of the chosen ileostomy. A 20cm J-pouch was created and returned for the pouch anal
anastomosis to be carried out under direct laparoscopic vision. The last 5 cases were carried out using
a single port approach (SILS) from the proposed ileostomy site14.
Operative technique following previous subtotal colectomy
Pneumoperitoneum was established using a Verres
needle inserted in the left upper quadrant. This was replaced with a 5mm
optical port and 5mm 300 laparoscope. The latter was used to survey
a site for potential further ports or in deciding to go for an immediate
mobilization of the ileostomy (12mm port placed within a purse string once the
stoma was mobilized with additional 12mm umbilical and 5mm inferior RIF ports
i.e., the same as had been used for the previous colectomy)15. Single
port restorative proctectomy (Olympus Tri
port, Southend, UK) was used successfully in two cases after first
mobilizing the end stoma.
Analgesia was delivered via a PCA in 33 patients
with oral morphine, diclofenac and intravenous paracetamol in the remaining 38;
the latter was augmented by bilateral transversus abdominals plane (TAP) blocks16
in 23 cases. Patients were allowed fluids as tolerated, mobilized the following
morning and offered a light diet. Discharge was determined by the stoma nurse’s
assessment of competency at management of the new loop ileostomy. Catheters
were removed after two days.
Laparoscopic restorative proctectomy (LRPC) was
attempted in 71 patients (39 males); 41 had undergone a previous colectomy
& ileostomy (laparoscopic in 38).
The median age was 39 years (range 16-86) with a median BMI 24
(19-48kg/m2). Three had a cancer (Duke’s A, C and C) with a
median nodal yield of 30. 40 underwent a hand sewn W-pouch construction via a
Pfannenstiel incision whilst the most recent 31 patients had J-pouches
constructed and returned via the ileostomy site. Seven underwent a single port
(SILS) procedure (includes two procto-sigmoidectomies and ileo-anal pouch). There
were five early conversions (7%) due to widespread, four quadrant adhesions.
The median operation time was 210 minutes (range 75-330 minutes). There were no
intra-operative surgical complications (other than spouting the wrong end of an
ileostomy), or deaths.
Post-operative analgesia was provided by PCA in
33 patients for a median of 36hrs (range 24hrs - 7 days); 80% of PCAs were
discontinued by 48hrs. Median time
to full diet was 36hrs (4hrs-7days) with a median hospital stay of 7 days
(2-30). The median stay for the “incisionless” patients was 5 days, falling to
4 days in the single port cases (3-7). Complications included: gastric ileus (9), high-output
ileostomy (2), chest infection (2), PE, coagulopathy, anastomotic bleed &
leak. There were no complications for the SILS cohort.
Two patients received a blood transfusion. The anastomotic
bleed occurred on the first post-operative evening. He underwent a laparotomy
and evacuation of a haematoma four days later; the pouch was unaffected. The
patient unfortunately went on to develop a below knee DVT. A wrongly spouted
ileostomy was closed after a normal contrast study on day 9 (patient developed
a leak 5 days later and the pouch was defunctioned). There was a minor wound
Seven patients were readmitted (10%): high-output
ileostomy (2), reactive depression, anterior anastomotic leak (drained at EUA),
bolus obstruction (three admissions), DVT and reassurance/discharge home. Covering stomas were closed at between
1-6 months; all are fully continent, able to suppress urgency and report a
median pouch frequency of 4/24 hrs (2-8). Although function was not
formally assessed using validated questionnaire or scoring systems, and was
simply recorded as normal, impaired or absent, no patient admits to having new-onset
problems with potency, dyspareunia and/or micturition. Long-term complications
occurred in seven (10%) and included: incisional hernia following closure of
the ileostomy (3), anastomotic narrowing requiring dilatation under anaesthesia
(3) and a small bowel volvulus (no intra-abdominal adhesions) leading to mesenteric
ischaemia and death.
Continuous technological innovation has
encouraged surgeons to attempt more complex laparoscopic colorectal
interventions. The objectives remain the same: reduced postoperative pain,
early mobilisation, reduced rates of wound sepsis, rapid return of gastrointestinal
function, early discharge from hospital, return to normal life, avoidance of
incisional hernias and long-term improvements in cosmesis. Although
laparoscopic intestinal surgery has been employed in a variety of settings,
many traditionalists have been and remain, deeply skeptical about its
application to inflammatory bowel disease.
Several specialist centres have shown the
feasibility of laparoscopic restorative proctocolectomy5-13with complication rates similar to those reported with open surgery but
with a shorter hospital stay. A meta-analysis17
of nine studies (329 patients) compared open and laparoscopic RPC; 168 (51.1%)
underwent laparoscopic resection. Operative time was significantly longer
(86mins) in the laparoscopic group (p<0.001) and throughout the subgroup
analysis, but this finding was associated with significant heterogeneity.
Operative blood loss was lower (84mls) in the laparoscopic group. There was no
significant difference in post-operative complications. Although they reported
a median length of stay approaching 13 days for LRPC, a statistically
significant reduction in length of hospital stay was observed for LRPC in
high-quality studies and those studies reporting on more than 30 patients by
1.1 days (p=0.02 in both subgroups) and studies published in or since 2001 by
3.0 days (p=0.004) but not overall. The authors concluded that any potential
advantage of a laparoscopic ileal pouch surgery remains to be established.
Our length of
date data are considerably lower, yet similar to that reported by the Leeds
group13 whose median length of stay was 6 (3-26) days overall. This series represents our total experience of
LRPC and describes our move from using a traditional11-13,,15,17
Pfannenstiel incision to remove the specimen, transect the gut tube and create
a W-pouch followed by a postoperative PCA (median stay 7 days)9,
through to “incisionless” total laparoscopic resection with removal of the
specimen through the chosen ileostomy site and construction of a J-pouch
(median stay 5 days)11 to our current position of offering
single-port LRPC (median stay 4 days)14. This move has coincided with our move to “accelerated
recovery” using TAP blocks to avoid the unwanted effects of parenteral opiates
that delay recovery and discharge16.
The choice of
incision to complete the dissection and to deliver the specimen remains a focus
of debate. In much of North
America, Australasia17 and Europe11 a small
peri-umbilical incision with direct extracorporeal ligation of the mesocolic
vessels is popular. It remains our choice for performing resectional cancer surgery
where it is our belief that in combination with TAP blocks, pain control is
improved and recovery faster16,19. The fulcrum effect of using a linear stapler through a port, the
limitation in the angulation of currently available staplers and the need for
multiple firings are frequently quoted as being limiting factors in allowing
laparoscopic low rectal transection13,20,21.
Pfannenstiel incisions have been used to overcome these perceived problems13.
An alternative approach adopted by others is to use a supra-pubic port,
hand-port22 or incision. We have learnt through experience19
that it is possible in all but the largest of tumours and narrowest of android pelvises
to transect/staple the gut tube low down at the level of the pelvic floor using
an ATG45 (Ethicon Endosurgery, Bracknell, UK) introduced from the right
iliac fossa using two anterior-posterior firings. The secret is in
dissecting/defining the “gut tube” and pelvic floor (optimized by using a 300
laparoscope) and more importantly utilize the fulcrum effect of the port by
placing the stapler with a fully pronated forearm, flexed wrist and an
internally rotated, abducted shoulder. The linear cutter will flex and
close at 900 if the tip is pressed against a fixed structure
i.e., pelvic side wall/sacrum, a fist placed against the perineum; once the
pressure is released it will “return” to 450 and allow firing.
A Spackman uterine retractor22 not only helps with the dissection,
but once completed, keeps the vagina under tension and away from pouch anal
Although we would consider our 34% morbidity (all
complications plus readmissions) a little high (the comparable figure18
for segmental resection in our unit is 22%), it is vey similar to that reported
by others11,12,22,25. This
figure falls to a more acceptable 14% if one excludes gastric ileus and high
output stomas, which are more appropriately considered side effects of the
transverse colectomies and covering ileostomies. The DVT/PE occurred in a
patient who went on to be diagnosed as factor VLeiden deficiency. 51 (72%) patients
had an uncomplicated recovery. Sadly we were unable to match the 0% conversion
rate in 36 patients recently reported by the Leeds group13; dense
impenetrable adhesions necessitated early conversion in 7%, a rate similar to
Kienle et al11 8% in
50 patients. LRPC may have an important role in maintaining fertility; 71% of
34 female study patients were found to have no adnexal adhesions at laparoscopy
prior to ileostomy closure and no patient had adhesions affecting both
adenaxea)26. This figure is significantly lower than previously
reported for open operation with or without the use of adhesion barriers. The
one late fatality in this present series followed a small bowel mesenteric
volvulus; the complete absence of any adhesions, including the free edge of the
mesentery of the afferent limb of the pouch probably had a major role in its
Whilst all our patients, and in particular the
SILS subgroup were delighted with the cosmetic results of their surgery,
Dunker’s comparative study7, in which a midline wound was used, failed to
demonstrate a significantly higher body image score compared with that obtained
following conventional surgery; cosmetic scores, however, were significantly
higher in the laparoscopic group. This small study showed no difference in
functional outcome and quality of life scores between the two contrasting
approaches to treatment. The Mayo group27 examined a larger subset; 125
of 289 patients (43% responders) were questioned one year after operation
to evaluate sexual function, body image, and quality of life. There were no
significant differences in terms of demographics, complications, or long-term
functional outcomes between responders and those who did not. There were no
differences in results between laparoscopic and open patients using the three
survey instruments. Whilst orgasmic function scores were significantly lower in
men who underwent LRPC compared with open procedures, overall, sexual function
scores were equal to, or better than normal values for men but were lower in
women. Interestingly, overall body image and quality of life scores were above
the means published for the United States.
contentious whether laparoscopic rectal surgery itself is associated with a
higher incidence of bladder and sexual function compared with open surgery; 41%
of CLASICC1 patients reported a severe change in sexual function,
compared to 26% in the open group (not significant). The groups however were
poorly matched and there were more TMEs in the laparoscopic group. The Brisbane
group28 report a more appropriate 6% sexual dysfunction in 101 male
patients; this falls to 2% when the effect of radiotherapy is excluded. Whilst the pelvic dissection is
technically challenging, particularly when mobilizing a fibrosed defunctioned
rectal stump in a male with a narrowed pelvis, the magnification does afford a
superior view of the autonomic nerves, particularly behind the seminal vesicles
and a 300scope allows one to “look around corners”. The main problem
with laparoscopic TME is that it is very easy to tent the hypogastric nerves by
retracting in a cranial/lateral direction, particularly on the left hand side,
and if the operator is unaware of this difference from open surgery then it is
very easy to enter the presacral plane and damage the nerves. This effect is reduced if you do not
employ an assistant to hold the recto-sigmoid.
We have shown that laparoscopic restorative proctocolectomy
with ileo-anal pouch is technically feasible and can be performed without an
unduly lengthy operation or morbidity. More importantly, it is safe and
predictable with good functional outcomes. However, the procedure is difficult and technically
demanding and requires lots of concentration. No one should embark on LRPC
unless they are adept at laparoscopic TME and ultra-low rectal transection.
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